GOVERNMENT OF TAMIL NADU

DIRECTORATE OF TECHNICAL EDUCATION

TAMIL NADU ENGINEERING ADMISSION - 2022
Application Number: 306551

Personal Information
Name: JAYASURYA J Name of the Parent/Guardian: JAISHANKAR
Communication Address: 64,NORTH STREET,ADAIKAMPATTY PO Permanent Address: 64,NORTH STREET,ADAIKAMPATTY PO
State: Tamil nadu District: Perambalur
Taluk: Alathur Communication address pincode: 621118
Native District: Perambalur Civic status of Native Place: Village Panchayat
Date of Birth (DD-MM-YYYY): 17-11-2004 Gender: Male
Mother Tongue: Tamil Nationality: Indian
Nativity: Tamil nadu Religion: Hindu
Name of the Community: MBC & DNC Name of the Caste: Kurumba, Kurumba Gounder
Aadhar Number (optional): 242150287572

Special Reservation Information

Whether you are a candidate under quota for Eminent Sports person as per Ex-Servicemen (Only Army/Navy/ Air force services are Eligible): No
annexure-II, item No.22 of information brochure?:
No
Differently Abled Person: No Differently Abled Type: --
TFC Center for certificate verification:
Government Polytechnic College Keelaknavai, Perambalur - 621 104.

Scholarship Information
Parent Occupation: Agriculture Annual Income: 48000
Are you a First Graduate?: Yes Post Matric Scholarship (SC/SCA/ST/Converted Christians): No

School of Study Information

Category of School: State Govt Civic status of school location (+2): Municipality
Have you studied VIII to XII in Tamil Nadu?: Yes Have you studied from VI to VIII in private school under RTE and IX to XII in
Government School?:
No
Have you studied VI to XII in Government school?: No

Class Year of Passing Name of the school District State Block Category of
Govt.School

VI Std. 2016 Sowdambikaa Matric Boys Hr. Tiruchirappalli Tamil nadu Thuraiyur --
Sec.school, Thuraiyur

VII Std. 2017 Sowdambikaa Matric Boys Hr. Tiruchirappalli Tamil nadu Thuraiyur --
Sec.school, Thuraiyur

VIII Std. 2018 Sowdambikaa Matric Boys Hr. Tiruchirappalli Tamil nadu Thuraiyur --
Sec.school, Thuraiyur

IX Std. 2019 Sowdambikaa Matric Boys Hr. Tiruchirappalli Tamil nadu Thuraiyur --
Sec.school, Thuraiyur

X Std. 2020 Sowdambikaa Matric Boys Hr. Tiruchirappalli Tamil nadu Thuraiyur --
Sec.school, Thuraiyur

XI Std. 2021 Zamindar's H S S ,thuraiyur Tiruchirappalli Tamil nadu Thuraiyur --

XII Std. 2022 Zamindar's H S S ,thuraiyur Tiruchirappalli Tamil nadu Thuraiyur --

Academic Information
Qualifying Examination: HSC Name of the Board of Examination:
Tamil nadu Board of Higher Secondary Education
Permanent register number: -- HSC Roll number: 5456523
Qualified Year: 2022 HSC Group: HSC Academic
Group Code: Physics/ Chemistry/ Maths/ Biology Medium of Instruction: English
HSC maximum (total) marks: 600 HSC obtained marks: 518
SSLC maximum (total) marks: 500 SSLC obtained marks: 475
Have you applied for NEET ?: No Have you applied for JEE ?: No
Educational Management Information System(EMIS) Number: Community certificate number: TN-5201912112489
3315130350908358
Nativity certificate number (if applicable): --

Subjects Month Year Maximum Mark Obtained Mark

 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSION - 2022
Application Number: 306551

Permanent Register Num-

ber/Roll Number
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSION - 2022
Application Number: 306551

DECLARATION BY THE APPLICANT

I, JAYASURYA J (Son / Daughter) of JAISHANKAR hereby solemnly declare that the information furnished and the statements
given in the application and the enclosures are true, correct and complete. I further declare that should it be found otherwise, I will
be liable to forfeit my seat and / or removal from the rolls of the Institution at whatever stage of study I may be, besides making me
liable for criminal prosecution. I am fully aware that as per the directions of the Hon'ble Supreme Court of India and Tamil Nadu
Prohibition of Ragging Act 1997, Ragging is an offence, as is banned in the Institutions and anyone indulging in ragging is liable
to be punished such as expulsion from the Institutions and / or rigorous imprisonment up to 3 years, and / or fine up to Rs.25,000/-

Place:

Date: ( Signature of the Applicant )

DECLARATION BY THE PARENT/ GUARDIAN

I, JAISHANKAR (Parent / Guardian) of JAYASURYA J hereby solemnly declare that I am fully aware of the declaration made by the
applicant, and I declare and bind myself on the same terms contained in the above declaration. The statements and the information
given are true, correct and complete. If it is found otherwise, the applicant is liable to forfeit the seat and / or removal from the rolls
of the Institution at whatever may be the stage of study, besides making me liable for criminal prosecution I am fully aware that as
per the directions of the Hon'ble Supreme Court of India and Tamil Nadu Prohibition of Ragging Act 1997,Ragging is an offence,
as is banned in the Institutions and anyone indulging in ragging is liable to be punished such as expulsion from the Institution and
/ or rigorous imprisonment up to 3 years, and / or fine up to RS. 25,000/-

Place:

Date: ( Signature of Parent / Guardian )

Note: Guardian can execute the above declaration, only if both the parents are not alive.
 GOVERNMENT OF TAMIL NADU
DIRECTORATE OF TECHNICAL EDUCATION
TAMIL NADU ENGINEERING ADMISSION - 2022
Application Number: 306551

The following Certificates copy have to be uploaded to our system.

1. Transfer certificate
2. 10th Mark Sheet
3. 12th Mark Sheet
4. Permanent Community Certificate Card for MBC & DNC (Permanent card / Electronic form / Digitally Signed E-Certificate)
5. Income Certificate of the Parent
6. Special Reservation Form for Sports and relevant certificates
7. Special Reservation Form for Ex-Serviceman and relevant certificates
8. Special Reservation Form for Blindness & Low Vision and relevant certificates